Healthcare Provider Details

I. General information

NPI: 1447845102
Provider Name (Legal Business Name): PELNA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2021
Last Update Date: 03/04/2021
Certification Date: 03/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2012 HIGHWAY 160 W STE 19
FORT MILL SC
29708-8401
US

IV. Provider business mailing address

2012 HIGHWAY 160 W STE 19
FORT MILL SC
29708-8401
US

V. Phone/Fax

Practice location:
  • Phone: 757-717-8922
  • Fax:
Mailing address:
  • Phone: 757-717-8922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name: MOYOSORE AGIRI
Title or Position: ADMINSTRATOR
Credential:
Phone: 757-288-3604